Hysteroscopy

Introduction

A hysteroscopy is a procedure used to examine the inside of the uterus (womb). It is carried out using a hysteroscope, which is a narrow tube with a telescope at the end. Images are sent to a computer to give a close-up of the womb.

Why it is used

A hysteroscopy can be used to help diagnosis cases where a woman’s symptoms suggest that there may be a problem with the womb. Symptoms might include:

The surgeon will use a device called a speculum to open up the walls of the vagina, in the same way it is used during a smear test. The surgeon will then insert the hysteroscope through the cervix, into the womb.

Often gas or fluid is used to inflate the womb to give the surgeon a better view.

If a biopsy or treatment, such as removal of polyps, is needed, other instruments will be passed into the womb.

A hysteroscopy usually takes between 10 and 30 minutes, depending on what needs to be done.

Afterwards

You should be able to go home the same day as your hysteroscopy. If you had an anaesthetic you may have to stay in hospital until it has worn off.

Once at home you should rest as much as possible. Some women experience cramping, similar to period pain, afterwards. You may also get shoulder pain, which is an effect of the gas or fluid used to inflate your womb. Any cramps or pain should pass within a few days. You can take painkillers in the meantime.

Most women feel they can return to normal activities, such as work, the day after having a hysteroscopy. You may wish to have a few days off to rest. The amount of time you need off will depend on whether you had additional treatment at the same time (for example, to remove fibroids or polyps).

If you have had treatment at the same time as your hysteroscopy you will probably experience some bleeding afterwards. You may find that you need to wear a sanitary towel until this wears off.

Even if you did not have treatment, you may find you get some vaginal bleeding and discharge. This is normal and should pass in a few days, although it can last for several weeks.

You should not use tampons for at least one month after having a hysteroscopy, to help reduce the risk of infection.

Follow your surgeon’s advice on exercise, sex and contraception.

Getting your results

Your surgeon may give you the results of the hysteroscopy immediately if it is to explore conditions such as polyps or fibroids. They will be able to see these on the computer screen.

If a biopsy is needed, it can take between two and six weeks to get the results. These results may be sent to your home address by letter or to your doctor’s surgery. Check how you will get your results before leaving the hospital.

Risks

The most widely reported complications of a hysteroscopy – accidental damage, infection and excessive bleeding – are explained below.

Accidental damage

Accidental damage to the womb or cervix is the most common complication of a hysteroscopy, occurring in around 1 in 135 cases.

A section of the cervix can sometimes become torn, or the lining of the womb can sometimes be perforated (a hole is made in it).

Minor damage that does not cause excessive bleeding is not usually a cause for concern. But if a more significant injury is suspected, you may require a procedure known as a diagnostic laparoscopy. This is where a tiny camera is passed into your womb through an incision in your abdomen, to assess the damage.

In rare cases (around 1 in 700 cases) further surgery is then required to repair the damage.

Infection

In around 1 in 250 cases the womb or cervix becomes infected after surgery. This can lead to:

heavy bleeding

vaginal discharge that is smelly or unpleasant

a fever (temperature over 38°C/100.4°F)

stomach cramps

Most infections can be successfully treated using a short course of antibiotic tablets.

Excessive bleeding

Excessive bleeding, during or after surgery, occurs in around 1 in 400 cases. This can occur if a blood vessel is accidentally damaged.

If the bleeding begins during surgery the surgeon may be able to stem the bleeding by increasing the amount of fluid or gas in the womb. Often the increase in pressure helps to stop the bleeding.

If bleeding persists after surgery then one option is to insert a small balloon filled with fluid inside the womb. Much like gas or fluid, the pressure of the balloon helps stem the bleeding. The balloon is then removed 24 hours later.

An alternative method is to use medications such as vasopressin, which narrows the blood vessels and can help reduce bleeding.

Occasionally it becomes necessary to plug the blood vessel shut with small pieces of plastic or gel (this is known as embolisation).

In rare cases that fail to respond to treatment it may be necessary to remove the womb (hysterectomy).

The procedure

Before a hysteroscopy you may be referred for a number of tests to make sure it is safe for you to have surgery.

These tests may include blood tests, a pregnancy test and a cervical smear test to check for infection or any abnormalities with your cervix.

GnRH agonists

If you are having a hysteroscopy to remove abnormal tissue growth, such as fibroids or polyps, you may be given a type of medication called a GnRH agonist to take for a while before having surgery.

This helps shrink abnormal tissue growth, which can increase the chances of successful surgery and reduce the risk of excessive bleeding.

GnRH can cause menopausal-like side effects such as hot flushes and excessive sweating. These should pass when you stop taking the medication.

Choice of anaesthetic

It is possible to have a hysteroscopy with or without a local anaesthetic. This will usually be carried out in the outpatients department of a hospital.

A hysteroscopy should not hurt, as it is a similar sensation to having a smear test. However, if you are not having any anaesthetic, you may wish to take a painkiller, such as ibuprofen, beforehand.

The procedure can also be carried out under general anaesthetic (when you are asleep) as a day case operation. This may be recommended if your surgeon expects to do extensive treatment at the same time, or if you request it.

The procedure

The surgeon will gently put an instrument, called a speculum, into your vagina. This holds the walls of the vagina open enabling easy access to your womb.

Next, the vagina and cervix are cleaned with an antiseptic solution. The surgeon will then insert the hysteroscope through your cervix into your womb.

As the womb is small, gas or fluid may be pumped inside to make it larger. This helps the surgeon see the lining of the womb, and any abnormalities, more clearly. The camera at the end of the hysteroscope sends pictures from the inside of your womb to a video screen.

Surgical instruments similar to a hysteroscope can also be passed into your womb, if required, where they can be used to cut or burn away abnormal tissue growth. Tissue can be removed using a number of techniques such as lasers, electrical current and specially designed blades.

A sample of tissue can also be removed for further testing (biopsy) if required.

A hysteroscopy usually takes between 10 and 30 minutes depending on what needs to be done.

Why it is used

A hysteroscopy can be used to help diagnose a condition (diagnostic hysteroscopy) or to help treat a condition (therapeutic hysteroscopy).

Diagnostic hysteroscopy

Abnormal vaginal bleeding

One of the most common reasons for performing a diagnostic hysteroscopy is to help investigate abnormal bleeding from your vagina. Abnormal vaginal bleeding can be defined as:

The scarring can disrupt the normal female reproductive cycle and cause absent periods and infertility.

A hysteroscopy can be used both to diagnose intrauterine adhesions and to remove them by burning or cutting them away.

‘Lost’ IUD

An intrauterine device (IUD) is a small, T-shaped contraceptive device made from plastic and copper that fits inside the womb. It used to be called a coil or a loop.

An IUD should fit at the bottom of the womb near the cervix.

Occasionally, the IUD can move out of position and become ‘lost’ inside the womb. If this happens, a hysteroscopy can be used to retrieve and remove the IUD from the womb.

Müllerian anomalies

Müllerian anomalies are birth defects that affect the female reproductive system and cause absent periods and infertility.

Examples of müllerian anomalies include:

septate uterus – where the womb is split into two by a wall of tissue

bicornuate uterus – where the womb develops into a heart shape rather than the normal pear shape most wombs have

While not every type of müllerian anomaly can be repaired, many can be treated (and diagnosed) during a hysteroscopy.

Female sterilisation

A hysteroscopy can be used to sterilise you if you no longer wish to have children.

The hysteroscope is used to place implants inside the fallopian tubes (the tubes that release eggs into the womb). These implants trigger a build-up of scar tissue that eventually blocks the tubes, meaning that eggs are no longer released.

This method of sterilisation is very effective. It is estimated that for every 1,000 women who undergo this procedure only one will then go on to become pregnant.